Providers

Medical Policy Upcoming Updates

Notification Date: February 21, 2018

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Utilization Management

Policy Title	Status	Effective Date	Determination	Summary of Change
Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation) (III-TRA.01)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Heart Transplantation (Adult and Pediatric) (III-TRA.12)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria Appendix 1: Updated Heart Failure Classification
Heart/Lung Transplantation (III-TRA.08)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria Appendix 1: Updated Heart Failure Classification
Intestinal Transplantation (III-TRA.13)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Kidney Transplantation (III-TRA.03)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Liver Transplantation (III-TRA.02)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes to medical necessity criteria Transplant Evaluation: Qualifying criteria for alcoholic liver disease removed. Abstinence or enrollment in a chemical dependency program is no longer required for the transplant evaluation. Please Note: For the actual transplantation, there must be no active substance use disorder or for individuals with a recent (24 months) history of substance use disorder, there must be a successful completion of a chemical dependency program and 6 months of documented ongoing abstinence.
Lung Transplantation (III-TRA.11) (formerly titled: Lung Transplantation (Single or Double)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes to medical necessity criteria Removed specific criteria for double lung transplant. Single and bilateral sequential lung transplant criteria were combined and both require a diagnosis of end-stage pulmonary disease.
Mechanical Circulatory Support Devices (III-SUR.38)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Background: Ventricular Assist Devices: added new FDA approved VAD device, HeartMate 3™. Appendix 1: Updated Heart Failure Classification
Medicaid Home Care Nursing (HCN) Services (III-HOM.05)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Added documentation requirement that home health agency must retain documentation of face-to-face encounter. Definitions: Added definition of face-to-face encounter.
Medicaid Home Health Aide (III-HOM.04)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Added documentation requirement that home health agency must retain documentation of face-to-face encounter. Definitions: Added definition of face-to-face encounter.
Pancreas Transplantation (Pancreas Alone) (III-TRA.04)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Irreversible multisystem organ failure added as a contraindication.
Pancreas-Kidney (SPK, PAK) Transplantation (III-TRA.05)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Personal Care Assistance (III-HOM.03)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Added documentation requirement that home health agency must retain documentation of face-to-face encounter. Definitions: Added definition of face-to-face encounter.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
High Intensity Focused Ultrasound (HIFU) and Magnetic Resonance Guided Focused Ultrasound (MRgFUS) (formerly titled: High Intensity Focused Ultrasound (HIFU) Ablation Therapy)	Re-reviewed	04/23/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Long Term Ambulatory Cardiac Rhythm Monitors	Re-reviewed	04/23/2018	Covered	No change in determination
Pharmacogenetic Testing of the VKORC1 Gene for Warfarin Response	Re-reviewed	04/23/2018	Investigative and therefore not covered	No change in determination
Pharmacogenetic Testing to Predict Toxicity to 5-Fluorouracil (F-FU)/Capecitabine- Based Chemotherapy	Re-reviewed	04/23/2018	Investigative and therefore not covered	No change in determination
Transcutanous Electrical Joint Stimulation	Re-reviewed	04/23/2018	Investigative and therefore not covered	No change in determination

The updated clinical policies and guidelines above will be available as of their effective date, as noted. View policies and guidelines.

To request paper copies of a policy, please leave a message at the Medica Provider Literature Request Line: 1-800-458-5512, option 1, then option 8, then ext. 2-2355.

Where information conflicts with applicable state and/or federal law, Medica follows such applicable federal and/or state law.